FOUNDATIONS, COMPETENCIES, AND CURRICULAR GUIDELINES FOR BASIC TO DOCTORAL HOLISTIC NURSING EDUCATION. First Edition

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1 FOUNDATIONS, COMPETENCIES, AND CURRICULAR GUIDELINES FOR BASIC TO DOCTORAL HOLISTIC NURSING EDUCATION First Edition Published by The American Holistic Nurses Credentialing Corporation In concert with The American Holistic Nurses Association September 1, 2017 i

2 Foundations, Competencies, and Curricular Guidelines for Basic to Doctoral Holistic Nursing Education, Edition 1 is available for digital download without charge from October 15, 2017 to September 30, Several tool kits, designed to facilitate faculty in the design, development, and implementation will be released January 1, 2018-September 30, Links for the available downloads will be announced at Copyright 2017 American Holistic Nurses Credentialing Corporation. All rights reserved. Reproduction or transmission in any form is not permitted without written permission of the American Holistic Nurses Credentialing Corporation (AHNCC). This publication may not be translated without written permission of AHNCC. For inquiries, or to report unauthorized use, ahncc@flash.net. ii

3 AUTHORS Helen L. Erickson, PhD, RN, AHN-BC, FAAN is Professor Emeritus, The University of Texas at Austin. Helen has held faculty and administrative positions at The University of Michigan at Ann Arbor, University of South Carolina, and The University of Texas at Austin (UTA). She has also maintained a private practice; served as an international clinical and educational consultant; authored, co-authored books, chapters, and articles on theoretical Holistic Nursing; and developed and tested the holistic theory, Modeling and Role-modeling. She has received numerous awards, including AHNA Nurse of the Year and Life Time Achievement, and is recipient of the University of Texas, Helen L Erickson Endowed Lectureship on Holistic Healing. helenerickson@att.net Margaret E. Erickson, PhD, RN, APHN-BC, APRN, CNS is Chief Executive Officer, The American Holistic Nurses Credentialing Corporation. Margaret has taught baccalaureate and graduate didactic and clinical nursing courses at The University of Texas at Austin and Tennessee State University where her focus was to facilitate students in learning and implementing holistic theorybased practice. She has extensive clinical experience with practice extending across populations and settings; developed and tested a model for assessing bonding and attachment between mother and infant; and authored and coauthored chapters and article that describe relations among attachment, need satisfaction, human development processes, and self-care resources. ahncc@flash.net Mary Enzman Hines, APRN, PhD, CNS, CPNP, APHN-BC is Professor Emeritus, University of Colorado, Colorado Springs, Co-Owner of Integrative Pediatric Health Care, LLC. Mary is the past president of AHNA, a certified Pediatric Nurse Practitioner (CPNP-PC), certified Advanced Practice Holistic Nurse (APHN-BC), and a recognized researcher, educator, and consultant in Holistic Nursing and integrative healthcare. She has authored several chapters and articles on developing and implementing holistic graduate curriculum and education, advanced practice Holistic Nursing; her research focused on caring/healing in Holistic Nursing practice and advanced practice. Mary developed the first fully online holistic DNP program, funded by HRSA at the University of Colorado. Colorado Springs, and guided many graduate students to embrace and actualize a unitary, holistic clinical practice. She opened the first co-owned and operated integrative pediatric nurse practitioner practice in Colorado serving children and families seeking a holistic health experience. She has been recognized with several awards for her work in holism including the Holistic Nurse of the Year by AHNA. maryenzmanhines@aol.com M. Kay Sandor, PhD, RN, LPC, AHN-BC is a retired Professor of Nursing, The University of Texas Medical Branch, Galveston TX. Kay is a board certified Advanced Holistic Nurse (AHN-BC ) and a licensed professional counselor (LPC) and psychotherapist. Her specialty as a nurse psychotherapist is grief and loss and working with the actively dying. She is also a Benedictine Oblate with ties to the St. Scholastica Monastery in Boerne, Texas and Emmaus House in Charley Creek, Montana. She is also a Veriditas labyrinth facilitator. kay.sandor@gmail.com Deborah Shields, PhD, RN, AHN-BC, QTTT, CCRN, Professor, Capital University, Columbus, Ohio. Deborah Shields is a board certified Advanced Holistic Nurse and a qualified Therapeutic Touch practitioner and teacher. She has mentored baccalaureate and graduate student interested in the holistic paradigm and practice skills throughout her teaching career. She was Co-Editor and contributing author to the Seventh Edition Holistic Nursing: A Handbook for Practice. Deborah serves on served on iii

4 the Board of Directors of the American Holistic Nurses Association (AHNA) and as the AHNA Nurse Peer Review Leader. Deborah is also a staff nurse, caring for people experiencing peri-operative procedures. Her current practice and scholarship includes developing Holistic Nursing education curricula, integrating aesthetics into practice, and theory development. debshields@aol.com Mary Elaine Southard, DNP, RN, CNS, APHN-BC, HWNC-BC is Associate Professor, Graduate Nursing, College of New Rochelle. Mary Elaine has been a national/international leader, educator, author, and clinician in Integrative Health and Nurse Coaching with diverse experience, including population health management, insurance, information technology, oncology, primary care, and a private Integrative Consulting and Coaching practice in Scranton, Pennsylvania. She is Board Certified as an Advanced Practice Holistic Nurse and Nurse Coach and past Board Member of AHNCC. Her research focuses on using the Omaha System in Nurse Coaching as a key to practice, documentation, and information management. mescoach@aol.com. CONSULTANT Terri Roberts, J.D. RN is the Executive Director of the American Holistic Nurses Association, a position she has held since AHNA is the specialty nursing association for Holistic Nurses with a membership of 4500 with its headquarters in Topeka, Kansas. Prior to that, for 23 years she served as the Executive Director of the Kansas State Nurses Association (KSNA), the professional organization for registered nurses. Terri is a 1978 graduate of Washburn University School of Nursing and a 1982 graduate of Washburn University School of Law. She is a Past-President of the Kansas Society of Association Executives ( ). iv

5 OVERVIEW The increasing globalization of healthcare, changing demographics and expanding diversity of populations, and rapid technological changes mandate that nurses possess diverse skills and competencies to provide holistic, culturally sensitive healthcare (Institute of Medicine, 2001; 2003a, 2003b; 2010a, 2010b, 2010c). The Essentials of Baccalaureate Education (AACN, 2008), Essentials of Graduate Education (AACN, 2011), and Graduate-level QSEN Competencies: Knowledge, skills, and attitudes (AACN, 2012) delineate academic criteria required to prepare baccalaureate and graduate nurses, respectively. Concurrently, the Standards of Practice (ANA, 2015; AHNA/ANA, 2018) provide direction for state and national legislation of nursing practice. The recent shift in focus on personcentered care, health, and wellness indicates a need to compliment the Essentials to include knowledge, skills, and attitudes based in the foundations of holistic philosophy, theories, and health sciences that emphasize the inter-personal relations between nurse and consumers, dynamic relations among mind-body-spirit, the individual s perspectives as primary information, and factors that affect the individual s wellness and wellbeing. Holistic Nursing, an integration of science and art, is based in the belief that humans are unitary, energetic beings, open to and constantly interacting with the energy system of the universe (Rogers, 1989). The evolving pattern of the whole that results is an expanding consciousness (Newman, 1986). Holistic Nursing interventions are the creation of artistic actions, based on the sciences of caring, health, wellness, wellbeing, and healing. They are designed to facilitate the holistic person s growth, health, and healing (AHNA/ANA, 2018). Holistic Nursing practice focuses on creating inter-personal relationships needed to facilitate and enhance the individual s healing with the goal of a maximum state of health, wellness, and wellbeing (AHNA/ANA, 2018). They emphasize the natural integration of the parts of the whole in such a way that the holistic being is dynamic, interactive, and greater than the sum of the parts a holistic unity that cannot be reduced or separated, and is necessary for eudemonistic health, wellness, and wellbeing. The American Holistic Nurses Association (AHNA) and The American Nurses Association (ANA) provide an explication of Holistic Nursing that includes a detailed discussion of the scope of Holistic Nurses practice, their Core Values, Principles, Standards, and related Competencies (AHNA/ANA, 2018). The Core Values provide a philosophical context for practice and guide how Holistic Nurses think about the Standards and Competencies. The Principles of Holistic Nursing summarize the major themes of the Philosophy. The Standards set the norms or criteria for the Holistic Nursing practice; the Competencies explicate the activities and behaviors required of Holistic Nurses that are legislated through Nurse Practice Acts. Holistic Nursing, grounded in the discipline of Nursing, is congruent with relational ontology, ethic, philosophy, and values that define nursing s discipline, and its most mature evolution to the unitary level of scholarship and practice (Watson, J., 2017). This work complements the basic and advanced essentials of nursing by clarifying and standardizing required foundations and competencies of Holistic Nursing, and providing a formalized structure for educational curricula needed to seamlessly prepare Holistic Nurses across levels of education (Summer & Bickford, 2017). As such, it provides direction for unifying Holistic Nursing s education, research, and practice and presents evidence that nurses educated at the graduate level of Holistic Nursing are prepared to practice as Advanced Practice Holistic Nurses. Reflective guidelines are provided to facilitate understanding and use of the narrative that follows. v

6 REFLECTIVE GUIDELINES Grace, Willis, Roy, & Jones (2016) stated, Newman et al. published a focus of the discipline of nursing which built on earlier nursing scholarship to submit that the domain of inquiry of nursing is caring in the human health experience (Newman, Sime, & Corcoran-Perry, 1991). Since then, Newman s ideas have been revisited (Newman, Smith, Pharris, & Jones, 2008, E16), refined, and reified in the assertion that the caring, knowing presence of the nurse taps into what is meaningful for the patient. This focus regardless of underlying philosophical assumptions permits the unification of nursing practice, thus also knowledge development, across settings and countries (p. 65). This work is for all who practice nursing. Nursing has a social moral imperative to practice within its own discipline, not the discipline of medicine, or other professional groups. While knowledge from other disciplines might be used to clarify or validate nursing s discipline, it cannot direct or define our practice. Our practice, authorized by society, must be defined within the context of our social contract with society. Nursing s challenge to meet this social imperative is impacted by a lack of clarity of our purpose. Contemporary issues that affect social demands such as economic restraints and social-political factors, compound this state of affairs. The authors of this publication revisited these issues to determine what would help remove barriers between nursing s commitment to society and our current practices. While AHNCC had established a Holistic Nursing Endorsement Program in 1999, criteria for endorsement were primarily based on inclusion of basic Holistic Nursing precepts. Specific educational guidelines, consistent with the Essentials of Nursing Education were missing. This publication posits a formalized structure for educational curricula needed to seamlessly prepare Holistic Nurses across levels of education (Summer & Bickford, 2017). It contains the required components of nursing education based in the philosophy and values of Holistic Nursing, and provides direction for unifying Holistic Nursing s education, research, and practice. It is written within the context of evidence-informed practice as opposed to evidence-based practice. Our intent is to ensure that Holistic Nursing educational programs are designed to ensure students acquisition and ability to apply knowledge, skills, and attitudes of the Holistic Nursing discipline in their practice. Foundational principles of Holistic Nursing education, listed below, are described and explained by the narrative that follows. Foundational Principles of Holistic Nursing Education The role of Holistic Nurses, defined by the American Holistic Nurses Association and the American Nurses Association as caring-healing processes of holistic beings, is a moral, social imperative (AHNA/ANA, 2018). The Holistic Nursing discipline is based in the sciences of health, wellness, and wellbeing and framed by the unitary philosophy and science of energeticconnectedness of humans, environment, and universe. Unity of the whole requires that holistic nurses embrace all of the patterns of knowing as sources of information for building the discipline of Holistic Nursing. vi

7 Holistic Nurses embrace evidence-informed practice because it requires integration of the individual s personal needs and preferences, related evidence drawn from multiple sources, and the professional s clinical expertise (LoBiondo-Wood, Cameron, & Singh (2013; Pollard, 2008). Holistic Nursing mandates recognition of the dynamic interaction of research, practice, education, professional standards, and legislation. Each informs the other; each is necessary to develop the discipline of Holistic Nursing. Expertise is acquired through recognition, acquisition, and the artistic application of knowledge, skills, and attitudes framed by Holistic Nursing s philosophy, values, and theories and clarified by patterns of knowing. A structured, organized educational model based in these premises, consistent with the Scope and Standards of Nursing (ANA, 2015), and the Standards of Holistic Nursing (AHNA/ANA, 2018) will advance Holistic Nurses ability to more fully meet their social commitment. vii

8 This artistic expression, created by Kahiso Erickson (age 6), illustrates love and compassion within the human spirit as a means of connecting across time and space. It is presented here as a symbolic representation of the praxis of Holistic Nursing as discussed in the following pages. viii

9 FOUNDATIONS, COMPETENCIES, AND CURRICULAR GUIDELINES FOR BASICE TO DOCTORAL HOLISTIC NURSING EDUCATION TABLE OF CONTENTS I INTRODUCTION...3 Social Mandates Holistic Nursing Professional Considerations Evidence for Holistic Nursing II THE HOLISTIC NURSE ROLE...;...6 The Ethical Foundations of Holistic Nursing Holistic Nursing Roles Defined III OVERVIEW OF THE ESSENTIAL EDUCATIONAL REQUIREMENTS FOR HOLISTIC NURSING: BASIC AND ADVANCED...9 Conceptual and Philosophical Considerations Legislative Considerations Educational Considerations IV CURRICULAR THREADS FOR BASIC AND ADVANCED HOLISTIC NURSING PROGRAMS...10 A. Scientific Underpinnings of Holistic Nursing B. Clinical Scholarship and Application of Analytical Methods C. Ethics of Holistic Nursing D. Holistic Nursing Within and Across Delivery Systems V ESSENTIAL REQUIREMENTS FOR BASIC HOLISTIC NURSING...,...13 Educational Essential Requirements: Knowledge, Skills, Attitudes, and Behaviors Essential Requirement 1. Philosophical and Scientific Underpinnings for Practice Essential Requirement 2. Clinical Scholarship and Analytic Methods for Evidenceinformed Practice. Essential Requirement 3: Organization, Systems, Caring Leadership for Person- Centered Quality Improvement and Safety Essential Requirement 4. Basic Holistic Education and Research Support Dynamic Changes in Healthcare Essential Requirement 5. Informatics, Technology, and Person-Centered Care for the Improvement and Transformation of Holistic Healthcare Essential Requirement 6. Ethics, Policy and Advocacy in Holistic Healthcare 1

10 Essential Requirement 7. Inter-professional Collaboration for Improving Patient and Population Health Outcomes VI ESSENTIAL REQUIREMENTS FOR ADVANCED HOLISTIC NURSING...23 Advanced Holistic Nursing Programs Essential Requirements: Knowledge, Skills, Attitudes, and Behaviors Essential Requirement 1. Philosophical and Scientific Underpinnings for Advanced Holistic Nursing Practice Essential Requirement 2. Clinical Scholarship and Analytic Methods for Advanced Evidence-Informed Practice Essential Requirement 3. Organizations, Systems, and Caring Leadership for Person- Centered Quality Improvement, Economics of Healthcare and Thinking Theories Essential Requirement 4. Advanced Holistic Education and Research Support Dynamic Changes in Holism Essential Requirement 5. Informatics, Technology, and Person-Centered Care for the Improvement and Transformation of Holistic Healthcare Essential Requirement 6. Ethics, Policy, and Advocacy in Holistic Healthcare Essential Requirement 7. Inter-professional Collaboration and Leadership for Improving Patient and Population Health Outcomes VIII SUMMARY...28 REFERENCES/BIBLIOGRAPHY...29 APPENDIX A: BASIC HOLISTIC NURSE PRACTICE COMPETENCIES...31 APPENDIX B: ADVANCED HOLISTIC NURSE PRACTICE COMPETENCIES...37 APPENDIX C. TASK FORCE MEMBERS AND REVIEW PANELS

11 I. INTRODUCTION Background Nursing s Social Mandates Over the last few years, reports from the Institute of Medicine s (IOM) reports on quality of healthcare in the United States (2001) have initiated a shift in focus from disease to health and wellness (2003a). IOM recommended (IOM, 2003b, 2010a, 2010b) that nurses assume a leadership role in healthcare transformation. Legislators followed with the adoption of The Patient Protection and Affordable Care Act (HR3590) on March 23, 2010, sweeping the nation into a new paradigm for healthcare delivery and access (National Prevention, Health Promotion, and Public Health Council, 2011). Several interdisciplinary healthcare groups responded by launching models of integrative healthcare and/or coaching, articulated within the context of health and wellness. Nursing s social contract with society states that human s inherently manifest unity of mind, body, and spirit; the human experience is contextual, and culturally defined; and the presence of illness does not preclude health (ANA, 2010). Nurses, encouraged to further clarify their role within the context of health (Institute of Medicine, 2010a, 2010b, 2010c; 2012), drafted additional competencies required to practice graduate level nursing (American Association of College of Nursing (AACN, 2012), and revised Nursing: Scope and Standards of Practice (ANA, 2015). ANA clarified that: the central foci of nursing is caring and health; nurses address the individual s human responses to health and illness; they establish partnerships to coordinate care and maintain a healthy work environment; and the nursing process is used to plan and provide evidence-based holistic care. The ANA Scope and Standards (2015) also stated that graduate level competencies (AACN, 2012) link nursing s responsibility for quality improvement and safety with advanced patient-centered care that integrates...best current evidence with clinical expertise and patient/family preferences (p. 3). Holistic Nursing has adopted the term, evidence-informed practice (EIP) rather than evidencebased practice (EBP) because it more accurately reflects Holistic Nursing s position on the relations among ontology, ethic, philosophy, and values that defines the Holistic Nursing discipline and more accurately ensures the outcomes (Grace, Willis, Roy, & Jones, 2016, pp ). EBP requires integration of professional clinical expertise with evidence acquired through systematic research processes (Sackett, Rosenberg, Gray, & Haynes, 1996). In comparison, EIP requires the integration of the individual s personal needs and preferences, related evidence drawn from multiple sources, and the professional s clinical expertise (LoBiondo-Wood, Cameron, & Singh, 2013; Pollard, 2008). EBP can occur without consideration of the individuals worldview, while EIP is initiated with consideration of the individual s worldview, their perspectives on what caused or is associated with the situation, and what will facilitate wellness, healing, growth, and/or a peaceful transition. Holistic Nursing in the Forefront Holistic Nursing, organized in 1983, and recognized by ANA as a specialty (AHNA/ANA, 2007), is uniquely qualified to define the required educational foundations and competencies needed to advance Nursing s vision of a profession focused on person-centered caring that emphasizes unity of mind-body-spirit, and facilitates growth, health, wellness, wellbeing, and healing of the holistic being, within a culturally sensitive, evidence-informed practice designed to predict optimal outcomes. (ANA, 2010b; AHNA/ANA, 2018; Helming, Barrere, Aviono, & Shields 2014; Dossey & Keegan, 2016). 3

12 Senator Tom Harkins, former Chairman of the US Senate Health, Education, Labor, Pensions Committee, Healthcare Access and Reform Champion, recognizing the potential of Holistic Nursing, stated, Board Certified Holistic Nurses are part of Workforce 1 which means they are at the forefront of leading health promotion and fostering wellbeing for all populations, and they partner with others to transform the U.S. healthcare system to promote a true wellness society (March 17, 2015). Holistic Nurses base their practice on relations among core values, science, and nursing actions. The expected outcome of Holistic Nursing is a sense of being healthy, well, and/or experiencing wellbeing. Health is a perceived experience of wellbeing by the individual, and may or may not include a disease or condition. Symptoms are viewed as an...expression of the body s wisdom as it reacts to... its own imbalance or dis-ease (AHNA/ANA, 2018). On the other hand, an illness is an individual s subjective description of altered health or wellness. The unitary human s (Rogers, 1989) sense of wellbeing includes an ever-increasing expansion of consciousness (Newman, 1986). This, in turn, results in finding meaning in the health experience. Holistic Nursing s core values determine what sciences, knowledge, and skills are required to create artistic actions that are specific to the needs of the individual and aimed at growth, development, health, wellness, and healing. The sciences of Holistic Nursing are those that define and articulate: health, wellness, wellbeing, and healing; illness and disease as absence or deviation from health; and explain growth, development, healthy coping, healing, and transitional processes (AHNA/ANA 2018; Nightingale, 1859). Holistic Nursing actions are designed to purposefully promote normal human abilities (e.g. growing, adapting, healing, and transitioning). Therefore, Holistic Nurses use strategies that facilitate and guide these processes, protect individuals from elements in the environment that might impede their inherent abilities, and to prevent exposure to factors that could cause further assault on the individual s natural abilities. Holistic Nurses use presence (McKivergin & Daubenmire, 1994; McKivergin, 2009) to initiate and facilitate energetically connected relationships (Brekke & Schultz, 2006; Slater, 2013); themselves as compassionate, unconditionally accepting members of the human caring relationship (Quinn, 2014); self-care, and self-reflection (Levin & Reich, 2015; Reich & Levin, 2014) to reinforce their inherent and professional abilities; and reflection as a way-of-being in practice to enhance multiple ways of knowing that includes personal awareness and personal knowing (Erickson & Erickson, 2010; Johns, 2010). They set intent to be energetically connected; facilitate growth, health, wellness, and healing; and to create, apply, and evaluate artistic strategies based on the sciences of growth, development, health, wellness, and healing (AHNA/ANA, 2018). Holistic Nurses fulfill one or more roles, depending on their educational preparation. They assist individuals to make informed decisions about their personal health and wellbeing; promote the health and wellbeing of groups and society; provide leadership for groups or communities that aim to advance health within society; support and/or mentor colleagues who have an active role in the advancement of health within society; develop new programs based on the sciences of holistic health and wellness; and build new knowledge for the profession (AHNA/ANA, 2018; Enzman-Hagedorn, 2005, 2015). Holistic Nursing practice is based in the sciences of holism, growth, health, and wellness; their focus is on the relationship between provider and consumer. Specifically, Holistic Nurses believe the caring-healing processes can only be accomplished through a therapeutic partnership of provider and consumer with the Holistic Nurse acting as an instrument of health and healing (McKivergen, 1997, 4

13 2009), and consumers as experts of their own life experience. The caring-healing processes are designed with the intent of helping people experience quality and comfort in their lives and find meaning in their experiences, from birth through death. As stated by AHNA: Holistic Nurses honor the individual s subjective experience about health, health beliefs, and values. To become therapeutic partners with individuals, families, communities, and populations, holistic practice draws on nursing knowledge, theories, research, expertise, intuition, and creativity incorporating the roles of clinician, educator, consultant, coach, partner, role model, and advocate. Advanced Holistic Nursing practice encourages peer review of professional practice in various clinical settings and provides care based on current professional standards, laws, and regulations governing nursing practice (AHNA/ANA, 2013, p.5; 2018). Professional Considerations Evidence for Holistic Nursing Mason, Jones, Roy, Sullivan, and Wood (2015) elucidate the importance of Holistic Nursing practice. Thirty-nine groups of nurses whose practice models had demonstrated financial savings and improved access to care were studied. Qualitative analysis of the interviews showed that there were four themes common to all of their practices. They were identified by the authors as health was defined as holistic; individual-family-community-centric approaches to care, putting the people and concerns ahead of provider-defined priorities; relationship-based care enabling individual/family/ community engagement and partnerships that are time consuming to create yet crucial for building activation; and, a shift from episodic individual care to continuous group and public health approaches. The practitioners viewed health as holistic, centering on the integration of physical, psychological, social, spiritual, and functional capacity; quality of life; and personal happiness and wellbeing...dependent on the patient s perspective (p. 545). Mason et al. wrote, The study participants view the individual, family, and community as the drivers of care. This embodies meeting people where they are rather than imposing provider expectations, protocols, and predesigned regimens (p. 546). Relationship-based care was described as moving away from the prescriptive this is how it is should be done to strategies that embrace the active engagement of the patient in his or her own care actions (p. 546). The importance of building trusting relationships takes time and follow-through and is required for practicing relationship-based care. The practices described in this study reflect Holistic Nursing in action how Holistic Nursing s Core Values, Principles of Care, Standards for Practice, and Core Competencies interrelate. Recent role-delineation studies affirm that Holistic Nursing competencies, identified and validated by practicing nurses, require specific knowledge, skills, and attitudes to implement the holistic caring process (AHNCC, 2012; Erickson, Erickson, Campbell, Brekke, Sandor, 2013). Competencies were based on the concepts required for person-centered, holistic care: nurse-client engagement; energetically connected relations; client as expert of own needs and primary source of information; humans as holistic beings with innate abilities to grow and heal; nurse as an instrument of healing; and self-care, self-reflection, and reflective practice. The findings from these studies reaffirm that Holistic Nursing is a way-of-being with people that facilitates an ever-increasing expansion of 5

14 consciousness; Holistic Nurses practice in various settings, with individuals across the lifespan; and the role of Holistic Nurses vary by educational level (Erickson, 2009; Erickson, et. al., 2013). They also confirm that Holistic Nursing competencies are based in knowledge, skills and attitudes that are needed to provide evidence-informed, person-centered caring that facilitates growth, eudemonistic health (Smith, 1981), wellness, wellbeing, and healing outcomes that lead to pattern recognition needed for expanding consciousness (Newman, 1986). The Ethical Foundation of Holistic Nursing II. THE HOLISTIC NURSE ROLE The role of Holistic Nurses is founded in a common set of core values. The core values determine the standards, while the level of education determines the sophistication of the competencies required to practice within the standards of care (Erickson, et. al., 2013). All levels of practice embrace the basic ethical perspective that the individual, viewed as the focus of the human caring process and primary source of information, is...honored in all phases of the healing process regardless of expectations or outcomes (AHNA/ANA, 2013, p. 6; AHNA/ANA, 2018). To clarify, Holistic Nurses believe that all people: Have an inherent ability to heal and find meaning in life experiences; Are unique, diverse, and inherently good; Know (at some level) what they need to heal, recover, and be well; and Illness is subjectively described and determined by the view of the individual. Holistic Nurses also believe that all things are connected, that there is unity of humans and environment, that synergy occurs among these, and that there exists a responsibility to protect the ecosystem and promote universal health (AHNA/ANA, 2013, pp 6-7). Environment is the context of habitat in which all living systems participate and interact...[it] includes both the external physical space (of the individual) and the internal physical, mental, emotional, social and spiritual experience (ANA/AHNA, 2013, p. 87). The holistic person and the external environment are in continuous, mutual interaction, one affecting the other, and cannot be separated. As instruments of healing, Holistic Nurses partner with persons, honor their worldviews, and prepare to enter into a caring-healing relationship. Personal self-care and self-development, self-reflection, self-awareness, centering, and intentionality are fundamental to each personal interaction with another. The essence of the interaction is intentionality that leads to presence. Presence allows for the development of a caring-healing space and energetic unity between nurse and client (AHNA/ANA, 2018). Holistic Nursing Roles Defined Advanced practice nursing roles are conventionally identified by populations, setting, care provided, health concerns, and educational preparation (ANA, 2015; NCSBN, 2008). Conversely the Holistic Nurse s role emphasizes the use of core values as a foundation for selection of knowledge, skills, and abilities required to practice; and practice occurs where ever an individual, family, or group wants or needs a Holistic Nurse, irrespective of the consumers specific healthcare concerns (AHNCC, 2013). Holistic Nursing practice may involve the direct care of individuals and/or any role that affects the way others provide care, such as clinician, coach, educator, researcher, healthcare team leader, etc. These roles are not necessarily exclusive, but may be combined. For example, Holistic Nurses who are 6

15 educators may also be clinicians and/or researchers; those who run research programs may also be educators; or healthcare team leaders may also manage an active, hands on practice (i.e. be a clinician). Rather than distinguishing them according to their primary role, Holistic Nurses are credentialed according to their educational preparation. Table 1 provides skills, identified and validated by practicing Holistic Nurses at varying levels of education. As shown, all Holistic Nursing practice is based in a set of core values, consistent with the philosophy of Holistic Nursing (AHNA, 2013, p. 7; AHNA, 2018). Extant Holistic Nursing theories (AHNA/ANA, 2018) are used to guide, define, and/or explicate Holistic Nursing practice. These philosophical and theoretical foundations provide a context for teaching all knowledge, skills, and attitudes needed to guide the actions of Holistic Nurses. That is, Holistic Nursing faculty are ethically bound to teach knowledge congruent with Holistic Nursing values and theories, and congruent with the unity of scholarship and practice. TABLE 1. PRACTICE COMPETENCIES COMPARED BY LEVEL OF EDUCATION 1. HOLISTIC 2. HOLISTIC PHILOSOPHY, CARING THEORY & ETHICS PROCESS BASIC: ADN Demonstrates ability to: Demonstrates ability to apply: 3. HOLISTIC COMMUNICATION, THERAPEUTIC EVIRONMENT, AND CULTURAL DIVERSITY Demonstrates ability to: HOLISTIC EDUCATION & RESEARCH Demonstrates desire and ability to: 5. HOLISTIC SELF CARE AND SELF- REFLECTION Demonstrate ability to: Discuss and describe caring and healing concepts. Discuss and describe core Holistic Nursing concepts (e.g. Holism, Presence, Intentionality, Unconditional Acceptance, Caring, Healing, etc. and Conceptually based Holistic Nursing to individuals, families, and groups, and Selected research findings in the various phases of the caring process. Create caring environments culturally sensitive and conducive to mutual growth and healing in client and nurse Advance personal understanding and expertise of Holistic Nursing through continued Education Apply concepts of self-care to self and others. Practices selfreflection BASIC: Baccalaureate Explain how they are used in one s personal and professional lives Demonstrates ability to: Demonstrates ability to provide: Demonstrates ability to use: Demonstrates: Demonstrates ability to: Articulate relations between caring and healing concepts. Discuss and describe relations among core Holistic Nursing concepts (e.g. Holism, Presence, Intentionality, Unconditional Acceptance, Caring, Healing, etc., and selected extant Holistic Nursing theories; and Theoreticallybased individual, family, group & community care using research findings, and Leadership in the advancement of Holistic Nursing in limited settings and healthcare arenas. Ability to apply research findings Culturally competent communicati on skills and techniques in the creation of caringhealing environments Continued growth in expertise of Holistic Nursing. Ability to facilitate others in advancing their understanding of Holistic Nursing. Ability to apply research findings in the practice of Holistic Nursing. Facilitate self and others advancement and application of self-care concepts/ actions. Practices selfreflection. 7

16 Explain how they are used in one s personal and professional lives. ADVANCED Demonstrates ability to: Provide leadership in the application, analysis, synthesis and evaluation of Holistic Nursing concepts/ theories in the practice of Holistic Nursing Demonstrates ability to: Provide sophisticated theoreticallybased, holistic care to clients incorporating, appropriate research findings; Synthesize clinical cases to evaluate nursing care effectiveness; Evaluate caring and healing activities in the nursing process; and Demonstrates ability to: Provide leadership in the creation and use of therapeutic environments; and Mentor others in the acquisition of cultural competence. Demonstrates: Continued growth in expertise of Holistic Nursing. Ability to provide mentorship and leadership in the advancement of Holistic Nursing; and Ability to design studies and analyze research findings related to the practice and advancement of Holistic Nursing. Demonstrates ability to: Synthesize and evaluate self-care concepts and actions and Provide leadership in the advancement of self-care and selfreflection in the health-care arena. Provide leadership for other healthcare providers in provision of theorybased, researchsupported care. Holistic Nurses practicing at the Basic level of Holistic Nursing are either ADN or BSN Registered Nurses; their certification credentials are HN-BC and HNB-BC respectively. Currently, Holistic Nurses at the Graduate level are prepared as an MSN Registered Nurses or MSN Registered Nurses with Prescriptive Authority; their certification credentials are AHN-BC and APHN-BC respectively. Given the trends in Nursing, it is appropriate to propose that the educational requirement for the APHN-BC will be the DNP and or PhD by the year 2027 (Summer & Bickford, 2017). Table 2 shows the distribution of competencies when mapped by Holistic Nursing Core Values and Level of Education. The data included in Table 2 was derived from the 2012 role-delineation studies completed in 2012 (Erickson, et. al, 2013). Nurses who practice at the basic level of education focus the majority of their practice on the caring process. The philosophy and ethics of Holistic Nursing is embedded in that domain. As nurses advance their education, they build on knowledge, skills, and attitudes learned and developed during their basic Holistic Nursing program, and refocus their attention on specific aspects of Holistic Nursing reflected in the change in percent scores for each of the Core Values. These data are based on the mapping of specific competencies shown in Appendices A & B, and mapped according to the Core Values (AHNCC, 2012). 8

17 TABLE 2. EDUCATIONAL LEVEL, HOLISTIC NURSING CORE VALUES, AND PERCENT OF COMPETENCIES RELATED TO EACH CORE VALUE Core Value 1 Core Value 2 Core Value 3 Core Value 4 Core Value 5 Holistic Holistic Caring Holistic Holistic Education Holistic Self Philosophy, Theories, Ethics Process Communications, Therapeutic Healing and Research Reflection & Selfcare Environments, & Cultural Diversity Basic 14% 63% 10% 7% 6% Graduate 5% 53% 21% 15% 6% Doctoral 4% 55% 21% 14% 6% III OVERVIEW OF THE EDUCATIONAL REQUIREMENTS FOR HOLISTIC NURSING: BASIC AND ADVANCED Philosophical and Conceptual Considerations Holistic Nursing education begins with the novice learner and extends to those who seek the terminal degree of DNP and/or PhD (Summer & Bickford (2017). It is a process of deepening the art and sciences of Holistic Nursing within the context of the philosophical foundations of holism. The guidelines presented herein delineate specific program outcomes at the baccalaureate and graduate levels of Holistic Nursing practice that are needed to prepare nurses to practice holistically, and provide care that addresses the needs of people across the lifespan, in any setting. Such care is guided, defined, and explicated by Holistic Nursing theories (AHNA/ANA, 2018). The integration of the core values, science, and art of nursing is fundamental to the practice of Holistic Nursing and serve as the curricula threads in Holistic Nursing Education. The sophistication of core value interpretation, sciences required, and artistic application increases with education, so that all Holistic Nurses practice from basic premises, and all increase their knowledge, skills, and attitudes as they increase their formal education. Coupled with professional experiences, formal and informal educational experiences are based in the core values of Holistic Nursing, directed by the standards of care, and specified by the competencies required for practice. The relationship between and among the core values, standards of care, and competencies of Holistic Nursing have been validated by the American Holistic Nurses Credentialing Corporation through expert review and role-delineation studies (Dossey, Frisch, Forker & Lavin, 1998; Erickson, 2009; Erickson, Erickson, Campbell, Brekke, M., & Sandor, 2013). Competencies are the required behaviors identified by Holistic Nurses that are necessary for professional Holistic Nursing practice. They emerge from Holistic Nursing s core values, and are specific to Holistic Nurses Standards of Practice. As such, Holistic Nursing competencies are the result of integrating philosophy, core values, and science. While nursing s ethical statements have identified relationships between the science and art of nursing, and nursing s practice statements explicate their integration, little has been said about how nursing s core values drive the science of nursing; how the art of nursing emerges from the integration of core values and science of nursing; or how the art of nursing drives nursing research. Holistic Nurses perceive that the core values are inextricably connected to the science required to practice Holistic Nursing so that they inform one another in a 9

18 cyclic manner. Further discussion and clarification of Holistic Nursing concepts can be found in the American Association for Holistic Nursing: Scope and Standards for Practice (AHNA/ANA, 2018). Legislative Considerations Holistic Nurses in the United States are licensed to practice nursing in their individual state, commonwealth, or territory according to their professional nurse practice acts. All Holistic Nurses are required to be licensed according to the professional role they perform. The knowledge and skills required for licensure are cumulative, basic to advanced. It is expected that all graduate prepared Holistic Nurses are proficient in, and build on basic knowledge, skills, and attitudes as they acquire advanced education. Registered Holistic Nurses practicing at the basic level are required to have an Associate Degree or Baccalaureate Degree in Nursing (HN and HNB respectively). Registered Advanced Holistic Nursing and Registered Advanced Practice Holistic Nurses (AHN and APHN respectively) are required to have a Masters Degree in Nursing. Board Certified APHNs must also demonstrate proficiency in additional knowledge and skills consistent with their practice role. It is proposed that the APHN will require a DNP or PhD in Nursing by 2027 (Grace, Willis, Roy, & Jones, 2016). Professional Considerations A few schools currently offer programs that align courses in basic Holistic Nursing with courses based on the Baccalaureate Essential Requirements. Faculty who practice within the Holistic Nursing paradigm are usually able to do this without much difficulty. Those who teach at the graduate level have also found ways to integrate the graduate requirements into their Advanced Holistic Nursing courses (Erickson, M. 2017). These hybrid graduate programs may or may not emphasize a patient population. For example, adult nurse practitioner/holistic nurse practitioner programs are not uncommon. On the other hand, some schools offer a holistic nurse practitioner program or an advanced Holistic Nursing program that emphasizes care of individuals and groups across the lifespan. While these proactive programs have produced outstanding Holistic Nurses, the lack of a common set of guidelines for Basic and Advanced Holistic Nursing education creates constraints for many faculty and administrators who wish to develop or revise curricula needed to prepare nurses within the holistic paradigm (AHNCC, 2013). Program guidelines that include curricular threads for basic and Advanced Holistic Nursing programs are necessary to advance person-centered, evidenceinformed Holistic Nursing as defined by the 2015 ANA document: Nursing: Scope and Standards of Practice (2015). IV CURRICULAR THREADS FOR BASIC AND ADVANCED HOLISTIC NURSING PROGRAMS The following paragraphs introduce the curricular threads that provide an educational foundation for all Holistic Nursing practice. These are further described in relation to Basic and Advanced Holistic Nursing within the respective section found on the following pages. 10

19 Scientific Underpinnings of Holistic Nursing Holistic Nurses draw from the basic and behavioral sciences; the foundation of Holistic Nursing is the sciences of holism, health, wellness, wellbeing, and healing. These include, but are not limited, to those that address: Normal, healthy processes such as anatomy, physiology, microbiology, chemistry, psychobiology and psychoneuroimmunology; Energy theories based on quantum physics; and, Human growth and development from conception through transcendence. These sciences describe, explain, and/or predict normal holistic processes, as well as alterations and deviations that result in illness, sickness, and/or disease. Rather than emphasizing the outcome of these alterations and deviations, Holistic Nurses focus on the root of the problem what stimulated the response that affected the normal processes, causing them to deviate from health and wellness. Nursing theories that reflect core values of Holistic Nursing, draw from these sciences, and propose what nurses can do to intervene to address the root of the problem. The Holistic Caring-Healing Process is dynamic, cyclic, spiraling, and non-linear. There is an intentional focus on integration, unity, and healing of the holistic person. Clinical Scholarship and Application of Analytical Methods Holistic Nursing practice is built on research and informed by evidence. Evidence-informed practice is the process of using philosophy and theories, information and resources, research, clinical expertise, traditional and historical data, and patient preferences in person-centered shared decisionmaking (AHNA/ANA, 2018). Holistic Nurses utilize a breadth of integrative, complementary, and conventional therapies, applied within the context of Holistic Nursing Core Values, and drawn from Holistic Nursing knowledge. Holistic Nursing is more appropriately identified as a way-of-being with others, rather than a way-of-doing nursing practice. Caring is the core of nursing practice. Holistic Nurses bring their holistic selves into an energetically-connected relationship to protect the vulnerability, humanity, and dignity of another. This reinforces the meaning and experience of oneness and unity. Within this sacred space, a healing relationship emerges. These relationships are built and enhanced through holistic communicated, demonstrated by the characteristics of authenticity, empathy, compassion, love, warmth, trust, confidence, credibility, competence, honesty, courtesy, respect, and sharing of expectations. Holistic Nurses express, contribute to, and promote nursing as the integration of the art and science of the caring process, based on an understanding of: A philosophy of nursing that values healing as the outcome; The human health experience as a complex, dynamic relationship among health, wellness, illness and disease; and Energetically-connected, relationship-based care. The enactment of the philosophical principles of person, healing/health, practice, nursing roles, self-care, self-reflection, and reflective practice serve as the framework for Holistic Nursing. Clinical Scholarship emerges from these relational experiences. The research traditions that inform Holistic Nursing Practice draw from both qualitative and quantitative traditions guiding the exploration of these 11

20 relational and unitary phenomena. Ethics of Holistic Nursing Healing is an emergent process of the whole system, bringing together aspects of one s self and the body-mind-emotion-spirit-environment at deeper levels of inner knowing, leading toward integration and balance, with each aspect having equal importance and value. Healing leads to complex levels of personal understanding and meaning, and is synchronous but not synonymous with curing. The healing process is a continual journey of change and evolution of one s self through life, characterized by the awareness of patterns that support or are the challenges and barriers to health and healing. Holistic ethics is the foundation of this unfolding journey of understanding the Unitarian Human Being (Rogers, 1989). This understanding is supported through explorations of concepts of self, environment, humanity, and energetic connections. In this framework, acts are not performed for the sake of law, precedent, or social norms, but rather from an ethical desire to do good freely. Essential knowledge, skills, and attitudes needed to understand the unity of humans and environment is acquired through the exploration of three major processes: reflective practice, holistic selfdevelopment, and self-care. Reflective Practice serves as the guide for understanding meaning within practice (Johns, 1995, 2006, 2009, 2010). He states, Reflective practice is essential learning through experience, moving forward, gaining insights, realizing a vision of desirable practice as a lived reality, and direction to practice (p. 312). He argues that self-reflection is a way-of-being, results in knowing-in-practice, and finding meaning in the human interactions inherent in practice. Self-reflection is prerequisite to reflective practice. Holistic self-development, the practice that cultivates inner-strength and deepening wisdom, emerges from reflective practice. Holistic self-development begins with finding stillness a contemplative practice that creates a space for being and listening. This allows engagement in selfreflection, a turning inward to explore one s thoughts, values, beliefs, experiences, and behaviors. This leads to personal knowing, enhanced self-awareness, understanding, and inner wisdom. Ultimately, this illuminates self-care practices that best serve the individual. Holistic self-development, is necessary for service to others, growth and change in one s wellbeing, and understanding of one s personal journey. The nurse values a personal call to Holistic Nursing as a life purpose. Through selfdevelopment, people find meaning in their journey and discover their life purpose. Reflective Practice serves as the guide for this holistic self-development process (Shields & Stout-Shaffer, 2016). Holistic self-care is not the ability to manage activities of daily-life, but the ability to take care of one s self in multiple ways that facilitate holistic growth, development, and healing (Erickson, 2006, p. 22). Holistic self-care has three dynamically, interrelated dimension: self-care knowledge, self-care resources, and self-care actions. Self-care knowledge is what people know about their health and wellbeing, what has caused deviations, and what will help them move toward a sense of wellbeing, optimizing their effectiveness or fulfillment (Erickson, 1982, 2006). Self-care knowledge serves as the basis for one s personal model of the world (Hertz & Baas, 2006, p. 119). Holistic self-care resources are the resources one perceives that they have to help themselves get well, heal, grow and develop. They are both internal and external; internal resources are within oneself and external resources are those developed and experienced through human relations. External resources can also be 12